BACKGROUND:Transesophageal echocardiography (TEE) enables real-time assessment of the area of maximal compression (AMC) during cardiopulmonary resuscitation (CPR). Compression of the left ventricular outflow tract, aortic valve, or aortic root occurs in 30% to 50% of cases, potentially reducing the likelihood of return of spontaneous circulation (ROSC) and organ perfusion. OBJECTIVES:Assess TEE feasibility in identifying the AMC during CPR and correlate optimal alignment with end-tidal carbon dioxide (EtCO2) levels and ROSC rates. METHODS:In this prospective observational study, we enrolled patients with out-of-hospital cardiac arrest who were transported by ambulance to the emergency department (ED) for extracorporeal CPR (E-CPR) while receiving mechanical chest compressions. TEE was performed immediately on ED arrival to identify the AMC. RESULTS:AMC evaluation with TEE was feasible in all 18 enrolled patients. At ED arrival, mechanical compression was correctly aligned with the AMC in six (33.3%) patients. Compressions delivered on the AMC were associated with significantly higher EtCO2 values (mean, 33 mm Hg [AMC+] vs. 12.8 mm Hg [AMC-]; p = 0.004) and a greater likelihood of ROSC (odds ratio, 22; 95% confidence interval, 1.54-314; p = 0.011). However, no patient survived to hospital discharge. CONCLUSIONS:TEE-guided evaluation of AMC during CPR is feasible in out-of-hospital cardiac arrest patients considered for E-CPR and reveals that in only one third of cases, mechanical compressions are aligned with the AMC. Compressions aligned with the AMC were associated with higher EtCO2 values and ROSC rates, but not with survival to discharge.

Cogan syndrome, a rare multisystemic autoimmune vasculitis, can result in coronaritis and precipitate acute coronary syndrome. This paper reports a case of a young woman affected by Cogan syndrome with acute coronary syndrome due to a left main lesion and the complexities in selecting the revascularization strategy for concomitant active vasculitis.

BACKGROUND:Accurate prognostication following cardiac arrest (CA) is crucial for informing clinical decisions. Current guidelines do not recommend a specific time point for recording somatosensory evoked potentials (SSEPs) after CA. We evaluated the ability of ultra-early short- and middle-latency SSEPs to predict good an poor neurological outcome and compared its accuracy with that of other predictors recorded early after CA. METHODS:Prospective single-centre study. Sixty-five comatose adults underwent a multimodal prognostic assessment, including neurophysiological (SSEPs and electroencephalogram [EEG]), clinical (pupillary reflexes and myoclonus), and imaging indices (brain computed tomography [CT]) within 6 h post-CA. Serum neuron-specific enolase (NSE) was sampled 12 h post-CA. We analysed the SSEPs N20 wave amplitude and duration, and the presence of the middle-latency N70 wave. Poor outcome was defined as a Cerebral Performance Category (CPC) of 3-5 at hospital discharge. RESULTS:A bilaterally absent N20 wave predicted poor outcome with 100[89-100]% specificity and 67[48-82]% sensitivity. Adding low-amplitude (<1.2 µV), prolonged (>10 ms) N20 waves without N70 increased sensitivity to 93[79-99]% without compromising specificity. Conversely, a high-amplitude (>3 µV) N20 wave with normal duration with preserved N70 predicted good outcome with 94[79-99]% sensitivity and 100[89-100]% specificity. SSEPs outperformed all other early prognostic indices for both good and poor outcome prediction. All poor outcome patients had at least two concordant unfavourable predictors. CONCLUSIONS:Ultra-early quantitative assessment of short- and middle-latency SSEPs provides highly accurate prediction of both good and poor neurological outcomes after CA. This approach may enhance early clinical decision-making and warrants validation in larger cohorts.

Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used to treat refractory cardiac arrest, although with variable results in survival and neurological outcomes. The intra-aortic balloon pump (IABP) showed mixed effects on survival in veno-arterial extracorporeal membrane oxygenation. Furthermore, the impact of IABP on survival and neurological outcomes in ECPR recipients has yet to be fully investigated. Methods We searched relevant databases for studies concerning ECPR recipients and intra-aortic balloon pump with information on survival and neurological outcomes. The inverse variance method (95 % confidence intervals) was used to determine the odds ratios of outcomes. We decided on a priori use of the random-effects model with the Hartung-Knapp adjustment. Results We included in our analysis nine cohort studies dealing with a total of 4994 patients. The association of IABP with ECPR was associated with a survival benefit compared to ECPR alone: 1029/3124 (32.9 %) patients survived in the ECPR+IABP group versus 379/1870 (20.2 %) in the ECPR group, OR 1.94, 95 % CI [1.36 to 2.77]. Survival with good neurological outcome was analyzed in 4 studies for 4018 patients. The association of ECPR and IABP was associated with a not significant advantage in survival with favorable neurological outcome compared with ECPR alone: 555/2687 (20.7 %) patients with good neurological outcome in the group of ECPR+IABP versus 149/1331 (11.2 %) patients in the group of ECPR, OR 1.33, 95 % CI [0.61 to 2.92]. Conclusions The association of IABP and ECPR significantly increases survival rates compared to ECPR alone. Nevertheless, the impact on favorable neurological outcomes remains uncertain.

Di Filippo, Chiara; Caniato, Flavia; Cappelli, Francesco; Mattesini, Alessio; Meucci, Francesco; Sori, Andrea; Stolcova, Mira; Agostini, Cecilia; Bernardo, Pasquale; Di Mario, Carlo Author Information

A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.)

Aims: To assess the accuracy of electroencephalogram (EEG) and somatosensory evoked potentials (SEPs) recorded at 12 and 72 h from resuscitation for predicting six-months neurological outcome in patients who are comatose after cardiac arrest. Methods: Prospective multicentre prognostication study. EEG was classified according to the American Clinical Neurophysiology Society terminology. SEPs were graded according to the presence and amplitude of their cortical responses. Neurological outcome was defined as good (cerebral performance categories [CPC] 1-3) vs. poor (CPC 4-5). None of the patients underwent withdrawal of life-sustaining treatment. Results: A total of 351 patients were included, of whom 134 (38%) had good neurological outcome. At 12 h, a continuous, nearly continuous and low-voltage EEG pattern predicted good neurological outcome with 71[61-80]%. sensitivity, while an isoelectric EEG and a bilaterally absent/absentpathological amplitude (AA/AP) cortical SEP pattern predicted poor neurological outcome with 14[8-21]%. and 59[50-68]%. sensitivity, respectively. Specificity was 100[97-100]% for all predictors. At 72 h, both an isoelectric, suppression or burst-suppression pattern on EEG and an AA/AP SEP pattern predicted poor outcome with 100[97-100]%. specificity. Their sensitivities were 63[55-70]%. and 66[58-74]%, respectively. When EEG and SEPs were combined, sensitivity for poor outcome prediction increased to 79%. Conclusions: In comatose resuscitated patients, EEG and SEPs predicted good and poor neurological outcome respectively, with 100%. specificity as early as 12 h after cardiac arrest. At 72 h after arrest, unfavourable EEG and SEP patterns predicted poor neurological outcome with 100% specificity and high sensitivity, which further increased after their combination.

In patients with severe cardiac dysfunction refractory to conventional therapies, extracorporeal membrane oxygenation used in veno-arterious modality can provide temporary circulatory assistance (extracorporeal life support, ECLS). Since it is an invasive and complex technique, its use is potentially burdened by severe complications, thus requiring careful nursing and medical care during intensive cardiac care unit stay. The use of ECLS requires specific skills such as knowledge of protective mechanical invasive ventilation, specific echocardiographic evaluation, accurate monitoring of hemodynamics and laboratory tests. A patient on ECLS is at high risk of thrombotic and hemorrhagic complications that could be fatal, hence specific pro- and anti-hemostatic therapy is needed. Moreover, the knowledge of some peculiar aspects of ECLS system and management can help doctors to avoid several complications such as limb ischemia, left ventricular overload and regional perfusion discrepancy. In conclusion, careful management by adequately trained personnel is required.

Questo tipo di metodica ha l’obiettivo di vicariare la funzione circolatoria di pazienti con un cuore ormai insufficiente per un periodo tale da permetterne il recupero funzionale (bridge to recovery), oppure da poter candidare o inviare il paziente a trapianto cardiaco (bridge to candidacy, bridge to transplantation) o da poter valutare la possibilità di altre strategie terapeutiche o di impianto di dispositivi di assistenza ventricolare sinistra (LVAD) (bridge to decision, bridge to bridge). È costituito da una pompa centrifuga, un ossigenatore, uno scambiatore di calore e da un sistema di cannule di drenaggio e reinfusione. Il tipo di configurazione più comune è quello con accesso periferico in cui il sangue viene prelevato dal paziente da una cannula inserita a livello di una vena periferica (di solito femorale) che drena l’atrio destro, è trasportato alla pompa centrifuga extracorporea che vicaria la funzione circolatoria generando un flusso di sangue continuo, viene quindi inviato ad un ossigenatore a membrana extracorporea INTRODUZIONE

BACKGROUND:Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients. METHODS:We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation. RESULTS:In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups. CONCLUSIONS:In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support.

BACKGROUND:Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients.METHODS:We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS.RESULTS:The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024).CONCLUSIONS:In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).

Background PAH is one of the most severe complication and cause of mortality in SSc, with frequent late diagnosis as asymptomatic in its early stages. Right Heart catheterization (RHC) is the gold standard for PAH detection, though its invasive nature with high risk of procedure related complications stress the need for developing new screening methods to investigate it in early and possibly reversible stages. Pressure Recording Analytical Method (PRAM) was recently developed to obtain a minimally invasive haemodynamic monitoring, using an arterial line and proximal pulsossimetry. This analyses arterial blood pressure curve and measure both cardiac [Cardiac Index, Cardiac Contractility and Vascular Stiffness ratio (dP/dT)] and vascular [vascular stiffness, elastance], which can be usually obtained only through RHC. Objectives to evaluate the clinical usefulness of PRAM method in SSc patients and to identify haemodynamic parameters related to increased risk of developing PAH. Methods 40 ssc patients (35 women, mean age 60±9,3 years; mean disease duration 7.5 years) were evaluated with both RHC and PRAM on the same day. Mean pulmonary arterial pressure (mPAP), cardiac index (CI), systemic vascular resistances (SVR), right cardiac power index (RCPI, calculated with mPAPXCIPRAM/451) were measured and concordance of the two methods was assessed through Bland-Altmann analysis. Systolic pulmonary arterial pressure and TAPSE from echocardiography, forced vital capacity, total lung capacity, both absolute and alveolar volume adjusted Carbone oxide lung diffusion (DLCO and DLCO/VA) from pulmonary function tests, blood tests parameters, nailfold videocapillaroscopy scleroderma patterns were recorded. Univariate and multivariate logistic regression analysis identified variables correlating with RHC-diagnosed PAH: a scoring system was then created, giving 1 point for value satisfying cut-off level. Results PRAM showed concordance with RHC estimate of CI and SVR within 95% interval confidence; 14 patients were diagnosed with PAH (mean age 64,4±9,3, mean disease duration 10.5 years, lSSc 61,5%). Multivariate logistic regression analysis showed DLCO (cut off value 47% obtained through ROC curve analysis, p=0.004) and RCPI (cut off value 0.12 Watt obtained through ROC curve analysis, p<0.001) as the most highly PAH-associated variables. When combining these two variables in the scoring system, patient with score=0 (DLCO<47% and RCPI<0,12 Watt), score=1 (DLCO<47% or RCPI≥0,12 Watt) and score=2 (DLCO<47% and RCPI≥0,12) were 0%, 21.4% and 78.6% of the PAH population respectively. Conclusions PRAM is comparable to RHC in detecting haemodynamic parameters such as SVR and CI. The scoring system combining DLCO and RCPI, obtained with non-invasive tools, could offer the possibility of detecting PAH patients with a high specificity. Disclosure of Interest None declared

The aims of the present investigation, performed in 118 consecutive patients with refractory ARDS treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), were as follows: (a) to assess ICU mortality in overweight, obese and morbid obese patients in respect to normal weight; (b) to evaluate echocardiographic findings according to BMI subgroups. Echocardiography was performed before VV-ECMO implantation. Forty-five patients (38.1%) showed normal BMI, 37 patients (31.4%) were overweight and the remaining were obese (21.2%), or morbid obese (9.3%). Morbid obese showed the lowest ICU mortality rate (p = 0.003). No differences were detectable among BMI subgroups in echocardiographic findings apart from the fact that obese patients showed the lowest incidence of LV dysfunction (p = 0.015). At stepwise regression analysis the following variables were independent predictor of ICU mortality (when adjusted for age): RV dilatation (OR 4.361, 95 % CI 1.809–10.512, p < 0.001), BMI (OR 0.884, 95% CI 0.821–0.951, p < 0.001). In other terms, the presence of RV dilatation is an independent predictor of ICU mortality. In refractory ARDS treated with VV-ECMO, BMI > 30 kg/m2 is common (accounting for one-third of the entire population) but it is not associated with a worse outcome, so that it cannot be considered per se a contraindication to ECMO implantation. The incidence of RV dilatation and failure, which are known to negatively affect prognosis in ARDS patients, were comparable among BMI subgroups.

OBJECTIVE Many extracorporeal membrane oxygenation (ECMO) centers for respiratory failure and ECMO mobile teams were instituted during the H1N1 pandemic. Data on transportation are scarce and heterogeneous. The authors therefore described the experience of their referral ECMO center for severe respiratory failure from 2009 to 2016 and gave a comprehensive report of transfers performed by their mobile ECMO team. DESIGN Observational retrospective study. SETTING An intensive care unit (ECMO referral center) in a teaching hospital. PARTICIPANTS One hundred and sixty consecutive patients with acute respiratory distress syndrome refractory to conventional treatment requiring veno-venous (VV)-ECMO. INTERVENTION VV-ECMO implantation. MEASUREMENTS AND MAIN RESULTS In this series, the transferred patients on ECMO averaged 57%, with annual percentages ranging from 28% to 90% over the years. No adverse event was observed during transportation. A progressive increase in simplified acute physiology score (SAPS) values and in the use of norepinephrine were detectable (p = 0.048 and p = 0.037, respectively) as well as in neuromuscular blockers use (p = 0.004). Dual-lumen cannule were more frequently used in recent years (p < 0.001). The overall mortality rate was 40% (64/160), with no differences over the years or between transferred and local patients. Body mass index and pre-ECMO neuromuscular blockers and SAPS were independent predictors for early mortality (when adjusted for age). CONCLUSIONS The workload of the authors' referral center and mobile team did not change, documenting that severe respiratory failure requiring VV-ECMO support is still a clinical need. No difference in mortality rate was detectable during this period or between transferred and local patients who were managed by the same team.

: Therapeutic hypothermia has been shown to reduce brain damage due to postcardiac arrest syndrome. Actually, there is no agreement on which is the best device to perform therapeutic hypothermia. The 'ideal' device should not only 'cool' patient until 33-34°C as fast as possible, but also maintain the target temperature and reverse the therapeutic hypothermia. For out-of-hospital cardiac arrest, there are devices that allow starting of therapeutic hypothermia on the field (prehospital hypothermia). On hospital arrival, these prehospital devices can be quickly and easily replaced with other devices more suitable for the management of therapeutic hypothermia in ICUs (in-hospital hypothermia). Some studies have compared surface and endovascular devices and found no substantial differences in neurologic outcome or survival at hospital discharge. On a clinical ground, the knowledge of the technical aspects of therapeutic hypothermia (such as characteristics of devices) is mandatory for clinicians who have to perform therapeutic hypothermia in cardiac arrest patients because the timing of therapeutic hypothermia, the choice of the device for the single patients, and avoidance of temperature fluctuation have shown to affect outcome in these patients (also in terms of reducing the incidence of complications).

BACKGROUNDThe aim of this study was to assess the incidence and prognostic role of echocardiographic abnormalities in consecutive patients with refractory acute respiratory distress syndrome (ARDS) before veno-venous extracorporeal membrane oxygenation (VV-ECMO).METHODSIn this study 74 consecutive patients with refractory ARDS underwent echocardiography (transthoracic, transesophageal or both, according to the best acoustic window). Baseline characteristics were collected for all patients and the simplified acute physiology score was calculated. At echocardiography the following parameters were considered: left ventricle (LV) ejection fraction, right ventricle (RV) size and function (by means of tricuspid annular plane excursion [TAPSE]) and systolic pulmonary arterial pressure.RESULTSAt echocardiography, 25 patients showed normal findings (33.8%), 32 patients exhibited isolated pulmonary hypertension (43.2%) and the remaining 17 patients showed RV dilation and pulmonary hypertension (23%). A reduced LVEF (<50%) was observed in 14 patients (18.9%), while RV dysfunction (as indicated by TAPSE<16 mm) was documented in 21 patients (28.4%). The in-Intensive Care Unit [ICU] mortality rate was 41.8%. At stepwise regression analysis the following variables were independent predictor for in-ICU mortality (when adjusted for TAPSE<16 mm): RV end diastolic area/LV end diastolic area (OR 0.21, 95%CI 0.062-0.709, P=0.012), Body Mass Index (BMI) (OR 0.87, 95%CI 0.802-0.958, P=0.004) CONCLUSIONS: In consecutive patients with refractory ARDS, echocardiographic alterations were common, mainly represented by systolic pulmonary hypertension associated or not with RV dilatation. Moreover, RV dilatation and BMI were independent predictors of in-ICU mortality. On clinical grounds, our findings strongly suggest that echocardiography helps to risk stratifying patients with refractory ARDS requiring VV-ECMO.

Although there are extensive published data regarding venous–arterial (VA) ECMO, particularly in the pediatric population, there is a paucity of data (mainly including case reports and observational studies) delineating the role of echocardiography in the management of adult patients supported by venous–venous (VV) ECMO. The present review is aimed at specifically addressing the rationale for echocardiography use in patients supported by VV-ECMO and at summarizing the available evidence on this topic. Based on the available evidence and on the experience of our group, practical considerations on the use of echocardiography in adult patients on VV-ECMO support are reported. To date, echocardiography is mainly used for selecting the type of ECMO (VA vs VV), monitoring cannulation and the early detection of complications, but it is underused in patients supported by VV-ECMO. Nevertheless, in these patients, this methodology can provide useful information in monitoring cardiac function, cannula positioning, pericardial fluid (for early detection of tamponade) during ECMO support, and therefore it can contribute to the integrated assessment and management of these complex patients. There is a clinical need to elaborate shared protocols for echocardiography use during VV ECMO support, particularly at this time when advanced echocardiography is gaining interest among intensivists.

Pandemic influenza virus A(H1N1) 2009 was associated with a higher risk of viral pneumonia in comparison with seasonal influenza viruses. The influenza season 2011-2012 was characterized by the prevalent circulation of influenza A(H3N2) viruses. Whereas most H3N2 patients experienced mild, self-limited influenza-like illness, some patients were at increased risk for influenza complications because of age or underlying medical conditions. Cases presented were patients admitted to the Intensive Care Unit (ICU) of ECMO referral center (Careggi Teaching Hospital, Florence, Italy). Despite extracorporeal membrane oxygenation treatment (ECMO), one patient with H3N2-induced ARDS did not survive. Our experience suggests that viral aetiology is becoming more important and hospitals should be able to perform a fast differential diagnosis between bacterial and viral aetiology.

BACKGROUND:Data on the hemodynamic and cardiovascular effects of hypothermia in patients with cardiac arrest are scarce. The aim of this study was to evaluate the hemodynamic changes induced by hypothermia by means of Most Care(®) (pressure recording analytical method, PRAM methodology), a beat-to-beat hemodynamic monitoring method.METHODS:We enrolled 20 patients with cardiac arrest (CA) consecutively admitted to our intensive cardiac care unit and treated with mild hypothermia (TH).RESULTS:While non-survivors showed no changes in haemodynamic variables throughout the study period, survivors exhibited a significant increase in systemic vascular resistance indexed during hypothermia and a trend towards lower values of heart rate and higher levels of mean arterial pressure.CONCLUSIONS:According to our data, PRAM methodology proved to be a feasible and clinically useful tool in CA patients treated with TH since it provides continuous beat-to-beat haemodynamic monitoring that is based on assessment of several haemodynamic variables. Moreover, we observed that survivors showed a different haemodynamic behaviour during hypothermia in respect to patients who died. However, further studies, performed in larger cohorts, are needed to better elucidate the haemodynamic effects of hypothermia in CA patients by means of PRAM methodology.